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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 198602069
Report Date: 06/10/2021
Date Signed: 06/10/2021 06:59:12 PM

COMPREHENSIVE INSPECTION
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754
FACILITY NAME:PALMCREST GRAND RESIDENCEFACILITY NUMBER:
198602069
ADMINISTRATOR:LESLY FIGUEROAFACILITY TYPE:
740
ADDRESS:3503 CEDAR AVENUETELEPHONE:
(562) 595-4551
CITY:LONG BEACHSTATE: CAZIP CODE:
90807
CAPACITY:262CENSUS: 118DATE:
06/10/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
09:30 AM
MET WITH:Morris StreicherTIME COMPLETED:
04:56 PM
NARRATIVE
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Licensing Program Analysts (LPAs) Ulysses Coronel, Stephanie Cifuentes and Jennifer Jones conducted an unannounced Required 1 year inspection. LPA's met with Assistant Administrator Peggy Clark and discussed the purpose for todays visit. The facility is a 2 story building, that is licensed for a capacity of 262 in which a total of 10 can be bedridden. There is currently a total of 118 residents (33 in the Memory Care Unit).

LPAs toured the entire physical plant which includes: reception desk, mail box area, administrative offices business offices, recreation area, beauty salon, utility closets, storage room(cleaning solutions and toxins were locked and inaccessible to residents), linen closets, 5 television areas(2 in memory care), medication room, kitchen, dining room, lounge/pool table area, restrooms, laundry room, and inspected randomly selected bedrooms on the first and second floor as well as in the memory care unit. All bedrooms were observed, pull cords in the bathrooms and bedrooms for emergency assistance were tested. Bathrooms contain grab bars, non-skid mats and are clean and operable. The 2 day supply of perishable and 7 day non-perishable food was observed to be in compliance. The water temperature was tested throughout the facility and averaged between 108.1 and 115.8 degrees F.

LPA Coronel reviewed resident records and observed that residents 5, 7, 8, 9 and 10 did not have Physician's reports and appraisal / needs and services plans within the last 12 months.

LPAs Jones and Cifuentes consucted a tour of the facility randomly inspected selected bedrooms and observed that: 1. the toilet in bedroom number 405 did not flush, 2. the electrical outlet in bedroom number 412 is missing a cover and 3. the floor inside the elevator (next to bedroom number 143 is cracked.)

California Code of Regulations, Title 22, Division 6 and Chapter 8 are being cited on the attached LIC 9099D. An exit interview was conducted Morris Streicher, Executive Director who was advised that a non-compliance meeting will be scheduled at a future date. A hard copy of this report and appeals rights were provided via email for signature.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:

DATE: 06/10/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 06/10/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
Page: 1 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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Reappraisals. The licensee shall arrange a meeting..., when there is significant change in the resident’s condition, or once every 12 months, whichever occurs first, as specified in Section 87467, Resident Participation in Decision Making.
This requirement was not met as evidenced by:
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Based on Record reviews the licensee failed to ensure that reappraissal meetings were conducted once every 12 months, 5 out of 10 resident records reviewed did not indicate that needs and services plan meetings were conducted within the last 12 months which poses a potential health and safety risk to clients in care.
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Type B
06/30/2021
Section Cited

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Maintenance and Operation. The facility shall be clean, safe, sanitary and in good repair at all times. Maintenance shall include provision of maintenance services and procedures for the safety and well-being of residents, employees and visitors.
This requirement was not met as evidenced by:
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Based on LPAs observation the licensee failed to ensure that the facility is safe and in good repair. During todays visit LPAs observed the toilet in Rm#405, the electrical outlet in Rm# 412 is missing a cover and the floor inside elevator near bedroom number 143 is cracked, which poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
Page: 2 of 3
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1000 CORPORATE DR #100
MONTEREY PARK, CA 91754

FACILITY NAME: PALMCREST GRAND RESIDENCE
FACILITY NUMBER: 198602069
DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 06/10/2021
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
06/30/2021
Section Cited

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Care of Persons with Dementia. Licensees who accept and retain residents with dementia shall be responsible for ensuring the following:Each resident ...shall have an annual medical assessment ... shall include a reassessment of the resident’s dementia care needs. This requirement was not met as evidenced by:
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Based on Record reviews the licensee failed to ensure that an annual medical assessment was conducted for residents with dementia, a medical assessment was not conducted for resident number 5 within the last 12 months which poses a potential health and safety risk to clients in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME: Janae HammondTELEPHONE: (323) 981-3328
LICENSING EVALUATOR NAME: Ulysses CoronelTELEPHONE: (951) 212-8917
LICENSING EVALUATOR SIGNATURE:
DATE: 06/10/2021
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 06/10/2021
LIC809 (FAS) - (06/04)
Page: 3 of 3